Over five million Americans suffer from chronic lower back pain, which has become the number one cause of lost work days in the United States. As a result, over 20 billion dollars are spent each year for the treatment of lower back pain, making it one of the most expensive health care issues today.
While the causes of lower back pain remain unclear, it is believed that 75% of cases are associated with degenerative disc disease, where the intervertebral disc of the spine suffers reduced mechanical functionality due to dehydration of the central disc region known as the nucleus pulposus. The reduction in the ability of the disc to transmit loads evenly and efficiently between vertebral bodies leads to damage in the annular region of the disc, known as the annulus fibrosis. Fissures or tears in the annulus can translate into a disc that herniates or ruptures, resulting in impingement of the nerves in the region of the disc. This impingement can lead to lower back or leg pain, depending on which nerves have been affected. Current treatments range from conservative bed rest to highly invasive surgical interventions (e.g., spinal fusion and discectomy) that are aimed at reducing pain but not at restoring disc function.
Spinal fusion is achieved by removal of the entire intervertebral disc, filling the gap or space with a bone graft and providing enough stability to the region through metal fixation plates and screws so that the vertebral bodies will fuse together. Although fusion serves to alleviate pain, the fusion does not restore the physiological biomechanics of the vertebral segment. In fact, the lack of motion within the segment can lead to further degeneration of the more distal intervertebral discs (Leong, J. C. et al. Spine 1983 793–799).
Discectomy is employed when the disc has herniated and is impinging on nerve bundles causing pain. In this surgery, the impinging region on the annulus fibrosis is excised, alleviating pressure on the nerves and eliminating pain. Like spinal fusion, however, this approach fails to restore physiological biomechanics of the vertebral segment. Further, the path of disc degeneration is likely to continue and spinal fusion in the future will likely be required.
An alternative approach to treatment of degenerative disease is to remove the diseased disc and replace it with a synthetic implant. Disc replacement may serve to eliminate pain while restoring physiological motion. Designs include low friction sliding surfaces, like a ball and socket (U.S. Pat. No. 5,258,031), spring and hinge systems (U.S. Pat. No. 4,309,777; U.S. Pat. No. 5,320,644; U.S. Pat. No. 4,759,769), contained fluid chambers (U.S. Pat. No. 4,083,477; German Patent DE-OS 3,741,493), and discs of rubber and other elastomers (Edeland, H. G. J. Biomed. Mater. Res. Appl. Biomater. 1989 23: 189–194; U.S. Pat. No. 4,911,716; U.S. Pat. No. 5,171,281). None of these concepts has proven effective in returning functionality to the spine segment. Spring and hinge systems cannot adapt to the changing center of rotation of the disc and fluid filled and elastic materials cannot survive the compressive and torsional loading of the spine biomechanics.
Limited clinical treatment with disc replacement has been performed. Human patients have been implanted with a hexene-based carbon black-filled polyolefin rubber core vulcanized to two porous-coated titanium plates (U.S. Pat. No. 5,071,437), with fracture of the rubber core experienced in 2 of 6 patients (Enker, P. et al. Spine 1993 18: 1067–1070). Clinical data is also available for the LINK disc replacement which consists of cobalt chromium alloy end plates and a polyethylene core (U.S. Pat. No. 4,759,766). In a 93 patient clinical trial, back pain relief was reported in only 20% of patients and leg pain relief in only 40–50% of patients after an average implantation time of one year (Griffith, S. L. et al. Spine 1994 19: 1842–1849).
Attempts have also been made to replace only the nucleus pulposus. Replacement of the nucleus pulposus is expected to arrest the initial dehydration of the degenerated nucleus and return the disc to a fully hydrated state so that the degenerative process, including the associated pain, is postponed or prevented and the mechanical function is restored to the vertebral segment.
Nucleus replacement was first attempted in the early 1960's with self-curing silicone which was injected into the disc space of cadavers (Nachemson, A. Bull. Hosp. Joint Dis. 1962 23: 130–132). Silicone showed early promise as a material for nucleus pulposus replacement until silicone synovitis and its associated complications led to limitation of the clinical use of the material (Cham, M. et al. Skeletal Radiol. 1998 27: 13–17).
Hydrogels are three-dimensional, water-swollen structures composed of mainly hydrophilic homopolymers or copolymers (Lowman, A. M. and Peppas, N. A., Hydrogels, in Encyclopedia of Controlled Drug Delivery, E. Mathiowitz, Ed., John Wiley and Sons, 1999. pp. 397–418)). These materials are for the most part insoluble due to the presence of chemical or physical crosslinks. The physical crosslinks can be entanglements, crystallites or weak associations such as van der Waals forces or hydrogen bonds. The crosslinks provide the network structure and physical integrity. For this reason, hydrogels have also been suggested as a useful material for nucleus replacement. In addition, they can be prepared with mechanical properties similar to the nucleus itself as well as with similar physiological properties, where it maintains about 70% water content under physiological loading conditions. U.S. Pat. No. 5,047,055 and U.S. Pat. No. 5,192,326 describe a hydrogel for use in nucleus pulposus replacement which is comprised of 100% semi-crystalline polyvinyl alcohol (PVA) PVA is a biocompatible polymer that has the ability to absorb water or physiological fluid and survive mechanical loading as would exist in the nucleus region of the intervertebral disc.
However, PVA is not entirely stable within the physiological environment of the body. PVA has been found to degrade through the melting out of smaller crystallites over time, thereby resulting in a reduction of mechanical properties and leaching of molecules into the physiological environment. Accordingly, these devices are limited by instability of PVA that results in mass loss and degradation of mechanical properties over time of immersion in vitro or implantation in vivo.
U.S. Pat. No. 5,976,186 discloses a prosthetic nucleus prepared from hydrogels of lightly crosslinked biocompatible homopolymers and copolymers of hydrophilic monomers, HYPAN or highly hydrolyzed crystalline PVA which exhibit an equilibrium water content (EWC) of from about 30 to about 90%. It is taught that partially hydrated xerogel rods or tubes of these hydrogels can be implanted into the nuclear cavity of an intervertebral disc wherein they can be brought to their EWC more rapidly due to their greater surface area.
The present invention relates to a modified PVA hydrogel for use in intervertebral disc replacement, and more specifically replacement of the nucleus pulposus, which has been stabilized by addition of a second polymer, preferably polyvinyl pyrollidone (PVP) or copolymers of PVP and poly(methyl methacrylate), poly(acrylamide), poly(acrylic acid), poly(acrylonitrile) or poly(ethylene glycol). Implantation of this new hydrogel is expected to be particularly effective in mammals, in particular humans, with early diagnosis of disc disease before the annulus has suffered significant degeneration.